Risk vs reward

When do we start drawing the line? By Stacy Fiscus
Recently, after reading an article about an air medical accident, I was rendered speechless. The part of the article I am referencing was an interview with a friend of a nurse who had been killed, and went like this: “When weather’s not good, one person can refuse and you can basically call the flight off if any of your staff feel that it’s unsafe.
“Being a nurse in that position, I would have never done that because that’s what you’re there to do, you’re there to go and get these babies and these kids and you’re to bring them to help. That’s why they’re calling you; they’re calling you to help them. 
“And she would have never said no. She knew somebody needed her and that’s just the person she was, she would never put herself above or in front of anybody else. She always put others in front of her. And that’s exactly why she died. She died putting someone else’s life ahead of her own.”
Now, I understand that this was a grieving friend and they meant well with this quote, but it got my wheels spinning. After being involved in the safety side of the industry for several years, I always hoped this type of thinking was part of our distant past. The civilian equivalent of mission completion at any cost. By the time we get to our medical flight careers, we are seasoned clinicians and pilots, yes? Should we, at this point, let the condition or age of a patient influence our fly-or-not decision-making when it comes to the well-being of ourselves and our crew?
We put as many safe-guards into place as we can, policies that dictate what a pilot and crew are told prior to launch. Larger companies create major distance between a communications centre and the crew. However, in smaller ones, communications or dispatch may be within hearing distance of the crew or just a short walk away. In many programmes, flight protocols require a launch when the scene or patient is 15 to 30 miles from the base and medically the launch is into the blind; eventually dispatch comes through and gives us the information we will need as the responding crew. What happens after this point is where the real crew resource management begins and brains must be used over emotion. Risk assessments are filed for each flight, but no number value can be placed on the human factor involved in these types of decisions and, in reality, should it take a number to tell a crew not to fly?
At any given time, there are generally three people onboard an air medical aircraft flying a patient flight. It has been said that it takes a great deal of bravery to stand up to our enemies, but just as much or more to stand up to our friends. Nearly every day, flight crews are put in this position. We live and work with our team mates and can say nearly anything to them. However, time and time again stories are told of crews being quiet to each other when in hindsight they all agree they should have spoken their mind or voiced their decision to abort the flight. But no one wanted to be first and suffer a perceived recrimination for calling it off.
I go back to the story at the beginning of this article. Though an official cause of this accident has not been released yet, ‘severe weather’ was reported in the area where they went down shortly after take-off. I wonder what the story is. It may not be pertinent to this subject. We don’t know what information the crew had or what the story was behind the scenes. But, what if they did feel such a duty to act that they decided it was worth the risk? When I was asked to author this column, I was asked to define what’s acceptable. I was introduced to a new line of thinking when it came to risk. “Our risk of flying the patient has to be lower than the risk of not flying,” with ‘risk’ being an overall assessment, considering the dangers of flying and the likely health outcome for the patient combined. At first glance, I would like to say that not flying is ALWAYS less risky than flying. But, if we never took calculated risk and flew our patients, then we wouldn’t exist as a profession.
So, we walk a fine line as professionals making decisions like these. We must always put ourselves and our crew first and ensure that we get home safely at the end of every shift. Policy and procedure help us to draw the line with steadfast limitations on weather, weight, and fuel capabilities. But, if those rules were the golden answer, then I wouldn’t be writing this column and the article mentioned earlier wouldn’t exist. Human factor plays a role in nearly 100 per cent of air medical accidents. It is the nature of the beast; I don’t think we will ever be able to write enough rules to cover every possibility human factor creates. Self-accountability is huge when it comes to walking the line that we do. Be accountable to yourself, your crew, and your family. If you wouldn’t put any of them in the aircraft for the flight you’ve been requested to do, or the one you are on, don’t put yourself in it.
I think of all the EMS families missing their loved ones and patients that could have been helped had all the clinicians and pilots killed in air medical accidents been alive to tend and to fly them. The person quoted was right; we all are the type of people that value human life and the preservation of it. We wouldn’t be in the medical field if we didn’t, but next time you find yourself struggling with saying ‘no’ because of this, remember the crews killed shortly after having this same struggle. A struggle that placed their job ahead of their own lives. After their deaths, the crews are lauded as ‘heroes’ and the industry mourns them as such, so why does this keep happening? Is that our aim, to be dead heroes? None of us want that, it is not worth it. Crews that took risks greater than their ability to handle them and that resulted in a senseless waste of lives made decisions that killed them. Make good decisions, be accountable, and draw the line for yourself and your crew. 


Stacy Fiscus is the Vision Zero chair for the Association of Air Medical Services and is also active as a board member at large for the International Association of Flight and Critical Care Paramedics, the IBSC, and the Air Medical Memorial. She is the lead contributor to the EMS Flight Crew Facebook page, and is a certified medical transport safety professional. Stacy resides in Port-Au-Prince, Haiti, where she is a flight paramedic and clinical base manager for the country’s first helicopter air medical transport service.